Provider Demographics
NPI:1558480491
Name:CLAIB CTY HSP PRO FEES
Entity Type:Organization
Organization Name:CLAIB CTY HSP PRO FEES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-321-1155
Mailing Address - Street 1:123 MCCOMB AVE
Mailing Address - Street 2:P O BOX 1004
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-2915
Mailing Address - Country:US
Mailing Address - Phone:601-437-5141
Mailing Address - Fax:601-437-8547
Practice Address - Street 1:123 MCCOMB AVE
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2915
Practice Address - Country:US
Practice Address - Phone:601-437-5141
Practice Address - Fax:601-437-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013195Medicaid
MS09013196Medicaid
MS09013197Medicaid
MS000019140OtherPROF FEE
MS09013196Medicaid
MSC00214Medicare Oscar/Certification